Telemedicine is a rapidly expanding method of care delivery that expands patient access to primary and specialty care; areas most impacted by physician shortages. There are a number of reasons for this increase—such as access to better technology, growing patient demand, cost effectiveness and lifestyle changes for physicians. Despite the advances in telemedicine usage and adoption, challenges remain in establishing and evaluating a successful, effective telemedicine program.

Telemedicine has been used to connect providers and patients in remote areas for more than 50 years, with a focus, in the last 10 years, on pilot projects demonstrating potential cost savings and increased access to care on a local level. Reductions in unnecessary transports, emergency department usage, and hospitalizations create savings to the overall health care delivery system and in turn hospitals are motivated to implement telemedicine as a method of care while addressing the gap in physician supply.

Currently, telemedicine is being used by hospitals for:

Supervision and consultation for primary care encounters in sites where a physician is not available.

Routine diagnostic evaluations based on history, physical exam findings and available test data.

A telemedicine consultation occurs when a provider cares for a patient, but the patient and the provider are in different geographic locations. The provider communicates with patients and/or other providers at a different location utilizing a variety of communication tools to exchange necessary medical information.

There are three main consultation categories: Live Interactive, Store and Forward, and Hybrid. In a Live Interactive consult, communication between the provider and the patient is usually facilitated through secure digital videoconferencing, which allows two-way audio and video communication. It is important for the transmission to be HIPAA compliant with appropriate bandwidth for the provider and the patient to achieve the desired consult outcome.

A Store and Forward consultation allows the originating provider to collect medical information from a patient, store it in the electronic medical record, and forward it to the consulting provider for evaluation such as in teleradiology and teledermatology.

Some small and rural hospitals utilize a combination of these two - a Hybrid consultation – and use components from both the live, interactive consultation and the store and forward consultation. These are typically used in dermatology or cardiology where higher quality images are imperative for diagnosing the patient’s condition.

Once a decision has been made to utilize telemedicine as a solution, there are several common steps, regardless of the service provider, to most effectively and seamlessly implement it at the hospital level.

Design
Create a Telemedicine Team including representatives from the Medical Staff, Information Technology, Finance, HR, Quality and Legal departments. Everyone should have a stake in the process to create buy-in and work toward the goal of implementing a program.

Identify needs
Create a list of health care services needed in the community. The team will need to analyze which of the needed clinical services can be provided via telemedicine with providers and patients in different locations.

Evaluate existing resources
Determine the current status and availability of the facility, technology, staff, and financial resources to deliver the solution. No matter which telemedicine vendor you choose, it is crucial to ensure the equipment is compatible with your overall health information technology plan. A good vendor should be willing to offer training to staff members.

Develop a financial plan
The team should focus on quantifiable program costs and revenues through utilization and projections. However, the team should also discuss the potential return on investment (ROI) related to reductions in unnecessary transports, ED utilization, inpatient hospitalizations and re-admissions. Vendors may have tools to assist in this process.

Implement the program
Before you officially launch your telemedicine project, you should test the program with the distant site. A mock consultation should be facilitated to test the equipment, participating staff and the connections.

Evaluate the program
The distinction between efficacy and effectiveness can pose a challenge to telemedicine evaluation. Efficacy refers to the benefit of using a technology for a particular health problem in ideal conditions of use. Effectiveness is the benefit of using a technology for a particular health problem in general or routine conditions of use, for example, in a community setting. In most health care applications, efficacy and effectiveness comparisons present trade-offs between internal and external drivers.

An all-inclusive evaluation of telemedicine is not necessary to demonstrate its effectiveness. If effectively consistent across a representative set of patient care applications, it is not necessary to evaluate for all indications. A good example is the case of antibiotics. It is commonly understood that antibiotics are effective as a treatment; they do not need to be evaluated every time they are used. However, it is necessary to demonstrate that a particular antibiotic is effective at treating a particular infection. Similarly, Grigsby et al. (1994) suggests narrowing the scope of evaluation, by selecting certain conditions to serve as indicators of the effectiveness of telemedicine.

The key to any effective evaluation tool is measurable criteria. There must be clearly identifiable program goals, objectives and outcomes. Here is a ist of possible evaluation questions:

Evaluating Quality of Care and Outcomes
- What were the effects of the telemedicine application on the clinical process of care compared to the alternative(s)?
- What were the effects of the telemedicine application on immediate, intermediate or long-term health outcomes compared to the alternative(s)?

Evaluating Access to Care
- Did telemedicine affect the use of services or the level or appropriateness of care compared to the alternative(s)?
- Did the application affect the timeliness of care or the burden of obtaining care compared to the alternative(s)?

Evaluating Health Care Costs and Cost-Effectiveness
- What were the costs of the telemedicine application for participating health care providers or health plans compared to the alternative(s)?
- What were the costs of the telemedicine application for patients and families compared to the alternative(s)?
- How did the cost of the application relate to the benefits of the telemedicine application compared to the alternative(s)?

Evaluating Patient Perceptions
- Were patients satisfied with the telemedicine service compared to the alternative(s)?

Although the questions about quality, access, cost, and patient and clinician perceptions are often considered independently, their interrelationships also warrant attention in an evaluation process.

Health care reform provides an opportunity to replace current fragmented and poorly coordinated care delivery practices with a more integrated model of care, supported by the use of technology-enabled innovations such as telemedicine. While their implementation into care practices can be disruptive to workflow and result in process changes to care delivery, this diffusion can lead to significant improvements in the quality and cost of care.